Approved form AF2002-174

made under the
Workers Compensation Rules 1938

Workers Compensation Rules 1938— Form 49
(see r 57 (6))

Order of reference to medical referee
[Heading as in application.]
On the application of			of			  , a copy of which is annexed, I appoint			, of			          , a medical referee appointed for the purposes of the Workers Compensation Act 1951, to examine [name of worker]			  and to give his or her certificate as to whether the incapacity of [name of worker]			  resulting from the injury is likely to be of a permanent nature or as to whether the absence of the worker from Australia is desirable for recuperative purposes.
A copy [or copies] of the report [or reports] of the medical practitioner [or practitioners] by whom the said			    has been examined is [or are] annexed.  [And, if so, copies of the statements submitted to me by the parties are also annexed.]
The worker,				, who is now at			, has been directed to submit himself or herself for examination by the referee.
I am satisfied that the worker,				is in a fit condition to travel for the purpose of being examined, and he or she has been directed to attend on the referee for examination at such time and place as may be fixed by the referee.
[Or, the worker,			     does not appear to be in a fit condition to travel for the purpose of being examined.]
The referee is requested to forward his or her certificate to the Registrar of the Magistrates Court, Canberra, on or before 					        , specifying therein the nature of the incapacity of 					      resulting from the injury, and whether such incapacity is likely to be of a permanent nature or whether the absence of the worker from Australia is desirable for recuperative purposes.
Dated:
Magistrate
[or Registrar of the Magistrates Court.]

Endnotes
1	This form was originally in the Workers Compensation Rules 1938, schedule 1.  Under amendments made by the Legislation (Consequential Amendments) Act 2001, the form was omitted from the rules and became a form approved under the rules, rule 89 (see amdt 1.2805, amdt 1.2807).
2	This republication includes amendments made under the Legislation Act 2001, part 11.3 (Editorial changes).

©  Australian Capital Territory 2002